MAX FAX Flashcards
What foramen does the ophthalmic branch of the trigeminal nerve pass through?
superior orbital fissure
What foramen does the maxillary branch of the trigeminal nerve pass through?
Foramen rotundum
What foramen does the mandibular branch of the trigeminal nerve pass through?
Foramen ovale
What is the origin, insertion, innervation and function of the muscles of mastication:
Masseter:
o Origin – zygomatic arch
o Insertion – lateral surface and angle of mandible
o Action – elevates and deep fibres retrude mandible
o Testing – clench teeth together
o Innervation – masseteric branch of mandibular division of trigeminal nerve
- Temporalis:
o Origin – floor of temporal fossa
o Insertion – coronoid process and anterior border of Ramus
o Action – elevates and retracts mandible
o Testing – clench teeth and palpate all fibres (anterior, middle and posterior)
o Innervation – anterior division of deep temporal nerve branches of mandibular division of trigeminal nerve - Medial pterygoid:
o Origin – superficial head (maxillary tuberosity) Deep head (Medial side of lateral pterygoid plate)
o Insertion – medial surface of angle of mandible
o Action – elevates and assists in protrusion of mandible
o Testing – intra oral can be painful
o Innervation – nerve to medial pterygoid of the mandibular division of trigeminal
nerve - Lateral pterygoid:
o Origin – lateral surface of lateral pterygoid plate and base of skull
o Insertion – pterygoid fovea and some fibres extend into the capsule of the TMJ
independent heads – inferior to head of consult; superior to intra articulate disc
Action- mandibular protrusion & depression
o Testing – response to resisted movement by putting finger far back of maxilla
and move jaw side to side
o Innervation – anterior division nerve to lateral pterygoid branch of mandibular division of trigeminal nerve
What is the pathology of a squamous cell carcinoma?
2 main factors involved:
* Genetic
* Carcinogens (environmental factors)
Damage alters gene expression - altering cell function.
Initiation- carcinogen causing genetic change.
Promotion- cell multifplication
Transformation- production of malignant cell.
Progression- forming malignant tumours.
Patient comes in with a right body mandibular fracture
- Other than pain, bruising and swelling. List 6 other signs and symptoms
associated with mandibular fractures
2020 Paper 1 Q9
- Limited function (opening and lateral movements)
- occlusal derangement = Can’t bite as normal into ICP
- Numbness lower lip
- Mobility of teeth/loose teeth
- Bleeding limited to area of fracture
- AOB
- –when ramus is shortened by trauma (posterior teeth meet prematurely)
—-Subcondylar (bilateral) Causes shortening In vertical height of ramus = AOB - Facial asymmetry
- deviation of mandible towards opposite side to fracture
- Bleeding in FOM = sublingual haematoma
- Steppy deformity of the teeth.
Two radiographic views required for mandibular fractures
2020 Paper 1 Q9
2 Plain views at 90 degree angles to each other
* OPT + posteroanterior mandible
OPT- Orthopantomogram
Other radiographs:
* Occlusal
* Lateral oblique
* Towns view
* SMV
* CT scan or CBCT
What factors cause displacement of mandible fractures? (6)
2020 Paper 1 Q9
- Direction of fracture line (Muscle can encourage or prevent displacement)
- Opposing occlusion: prevents fracture being displaced
- Magnitude of force
- Mechanism of injury
- Intact soft tissue: intact tissue = displacement unlikely
- Other associated fractures: > 1 fracture = higher chance of displacement
What are 6 signs and symptoms of TMD?
- Intermittent pain of several months or years duration
- Muscle / joint / ear pain, particularly on wakening
- Trismus / locking/limited mouth opening
- ‘Clicking/popping’ joint noises
- Headaches
- intra-oral signs: linea alba and tongue scalloping
What 2 muscles should be palpated when querying TMD?
masseter
temporalis
What are the common causes of TMD? (8)
- Myofascial pain (common. Problem with muscles due to overworking)
- Disc displacement (common)
– Anterior with reduction: where the disc slips forward but can move back to its original place
– Anterior without reduction - Degenerative disease (less common)
– Localised e.g. osteoarthritis
– Generalized (Systemic) e.g. rheumatoid arthritis - Chronic recurrent dislocation – condyle gets stuck in front of the eminence and mouth is locked open
- Ankylosis – condyle fused to the base of the skull (most people have a psudoankylosis)
- Hyperplasia – one condyle grows more than the other (can be bilateral but nota s common)
- Jaw moves to the opposite side from where the hyperplasia is
- Neoplasia (osteochondroma, osteoma, or sarcoma)
- Infection – can result in ankylosis
What 3 nerves supplies the TMJ?
auriculotemporal, masseteric, posterior (deep) temporal nerve
- Patients with TMJ pain can also experience discomfort in the ear as the auriculotemporal nerve also provides sensation to the external auditory meatus
What conservative advice is given to manage A patient with TMD?
Patient education!!
Counselling/reassurance: why its happening, how it happens, what the causes are, how we manage etc.
Advice: (standard approach)
* Reassurance
* Soft diet
* Masticate bilaterally
* No wide opening
* No chewing gum
* Don’t incise foods
* Cut food into small pieces
* Stop parafunctional habits e.g. nail biting, grinding
* Support mouth on opening e.g. yawning
Medication
- NSAIDs
- Muscle relaxants
- Tricyclic antidepressants (have muscle relaxant properties)
- Botox of masseter = prevents clenching (last resort tx)
- Steroids
Physical therapy
- Physiotherapy
- Massage/heat
- Acupuncture
- Relaxation
- Ultrasound therapy (not used as much)
- TENS (Transcutaneous Electronic Nerve Stimulation)
- Hypnotherapy and CBT
Splints
- Bite raising appliances
- Anterior repositioning splint e.g. wenvac or Michigan splint
What are the mechanisms of a bite splint using in TMD?
They stabilize the occlusion and improve the function of the masticatory muscles, thereby decreasing abnormal activity.
They also protect the teeth in cases of tooth grinding
- Eliminated occlusal interference
- Habit breaker
- Reduces loading on TMJ
- Prevents the join head from rotating so far posteriorly in the glenoid fossa
(same answer as above but lara order) x
Elimates occlusal interference
acts as a habit breaker
Reduces load on TMJ.
Improves function of mastiagtory muscles by decreasing the abnormal activitu and protecting the teeth in case of tooth grinding.
What is arthrocentesis?
Arthrocentesis = wash of the joint = increase lubrication
- Under LA or GA
- Inject lactate, hyaluronic acid and steroid into the capsule
- Can lead to reduction of the disc and increase function
Action: Breaks fibrous adhesion and flushes away the inflammatory exudate to increase lubrication.
Give 2 possible surgical options for TMD?
- Menisectomy = remove the disc completely
- Disc plication = move the disc to correct position
- Eminectomy = remove part of the boney eminence
What are 6 signs and symptoms of Zygomatico-orbital complex fractures involving orbit floor?
Diplopia and restricted eye movement
paralysis of eye
numbness under the eye
pain, bruising, swelling
flat face
facial asymmetry
What imaging would you take to confirm Zygomatico-orbital fracture diagnosis?
occipitomental view at 15 and 30 degrees
What are the management options for Zygomatico-orbital complex fractures? (7)
- initial and correction
Initial:
* Exclude ocular injury
* Prophylactic AB’s
* Avoid nose blowing
- Review once swelling subsided
- Further radiographs (+/- CT)
- Informed consent
Correction:
* Closed reduction +/- fixation
- howard gillies approach
* Open reduction + internal fixation
- Most corrections have ORIF
oral cancer
- What does dentally fit mean?
Patient who is free of pain & infection or future sources of pain&infection
OC - What is a multi disciplinary team?
A team of individuals from a variety of disciplines who work together to provide holistic treatment/care for a patient
List 4 members of an MDT for someone being treated for oral cancer?
Oncologist, special care dentist, Maxillofacial surgeon, speech and language therapist, physiotheraptist, radiographer
What risks is the patient at following radiotherapy, apart from mucositis? (5)
- traumatic Ulceration,
- mucositis
- Fibrosis of the muscles/soft tissues = Trismus
- xerostomia = Dry mouth from damage to the salivary glands
- Dental caries from the dry, acidic mouth
- dental erosion
- periodontal disease
- increased candida infections
- reactivation of herpes simplex virus
- Endarteritis obliterans (damge to the blood vessels supplying the bone) = osteoradionecrosis
What are the oral side effects of chemotherapy? (5)
Cytotoxic
* mucositis
* Decreased salivary gland function (Xerostomia)
Bone marrow supression causing:
* Defective haemostasis (Decreased neutrophils/ platelets/RBCs) increasing bleeding risk.
* Greater infection risk (Oral candidiasis/ Herpes simplex)
Neurological
* Trismus
* Joint pain.
Nausea/vomiting = erosion
Any teeth mineralising during chemotherapy- Disturbed root formation/ microdontia/ crown hyperplasia/ Hypodontia.
General conditions:
reduced RBC = anaemia
reduced WBC = leukopenia
reduced platelets = thrombocytopenia
reduced neutrophils = neutropenia
hairloss
fatigue/tiredness
What are the grades of mucositis?
Grade 0 = no alterations
grade 1 = pain and erythema
grade 2 = erythema and ulcers
grade 3 = ulcers (liquid diet)
grade 4 = unable to feed
How is mucositis managed? (3)
Avoid:
- Smoking
- Spirits
- Spicy food
- Tea and coffee
- Non-prescription mouthwash (esp those with alcohol)
Topical:
- Lignocaine gel
- Saline mouthwash (good for use in radiotherapy)
- Sodium bicarbonate mouthwashes (good for use in radiotherapy)
- Caphosol (manmade mucous/saliva sub)
- Tea tree oil mouthwash
- Cooling using ice cubes
low level laser light therapy
How can mandibular fractures be classified? (7)
- Involvement of the surrounding soft tissue;
* Simple: surrounding soft tissue intact
* Compound: fracture exposed to the surrounding environment (soft tissue breached)
Need AB’s
* Comminuted: multiple small fragments e.g. from gunshot - No of fractures
* Single
* Double
* Multiple - side of fracture
* Unilateral
* Bilateral - Site of fracture
* Angle
* Below condyle (subcondyle)
* Parasymphyseal (in the middle)
* Body
* Ramus
* Coronoid
* Condylar fracture (intra/extra caspular)
* Alveolar process - Direction of fracture line
* Favourable: direction of fracture line limits the displacement of the fracture by the action of the surrounding muscles
* Unfavourable: direction of fracture line encourages the displacement of the fracture - Specific fractures
* Green stick fracture: soft bone (children) very unlikely to completely fracture = still attachment in one of the cortices
* Pathological: fracture caused by pathology
e.g. osteoporosis, osteomyelitis, Padgets, expanding cystic lesion - Displacement of the fracture
* Displaced: requires surgical tx
* Undisplaced: may not require surgical intervention
How is a mandibular fracture managed?
2020 Paper 1 Q9
Control pain and infection - analgesia and antibiotic (if a compound fracture)
- Undisplaced = usually no tx
- Displaced or mobile fracture = surgical intervention
a) Closed reduction + fixation: reduce the fractured segments to their normal anatomical orientation without exposing the fracture line (we judge it using Intermaxillary fixation = if teeth go into ICP )
b) Open reduction + internal fixation
Reflect ST and expose the bone to reduce the segment
Open reduction and internal fixation (ORIF) = most common
What are the signs and symptoms of maxillary fractures? (7) *** have we done
Pain, asymmetry, diplopia, altered sensation, swelling, nose bleed, mobility.
